Abstract
Disorders affecting mental health are highly prevalent, can be disabling, and are associated with substantial premature mortality. Yet national health system responses are frequently under-resourced, inefficient, and ineffective, leading to an imbalance between disease burden and health expenditures. We estimated the disease burden in the Americas caused by disorders affecting mental health. This measure was adjusted to include mental, neurological, and behavioural disorders that are frequently not included in estimates of mental health burden. We propose a framework for assessing the imbalance between disease burden and health expenditures. In this cross-sectional, ecological study, we extracted disaggregated disease burden data from the Global Health Data Exchange to produce country-level estimates for the proportion of total disease burden attributable to mental disorders, neurological disorders, substance use disorders, and self-harm (MNSS) in the Americas. We collated data from the WHO Assessment Instrument for Mental Health Systems and the WHO Mental Health Atlas on country-level mental health spending as a proportion of total government health expenditures, and of psychiatric hospital spending as a proportion of mental health expenditures. We used a metric capturing the imbalance between disease burden and mental health expenditures, and modelled the association between this imbalance and real (ie, adjusted for purchasing power parity) gross domestic product (GDP). Data were collected from July 1, 2016, to March 1, 2017. MNSS comprised 19% of total disability-adjusted life-years in the Americas in 2015. Median spending on mental health was 2·4% (IQR 1·3-4·1) of government health spending, and median allocation to psychiatric hospitals was 80% (52-92). This spending represented an imbalance in the ratio between disease burden and efficiently allocated spending, ranging from 3:1 in Canada and the USA to 435:1 in Haiti, with a median of 32:1 (12-170). Mental health expenditure as a proportion of government health spending was positively associated with real GDP (β=0·68 [95% CI 0·24-1·13], p=0·0036), while the proportion allocated to psychiatric hospitals (β=-0·5 [-0·79 to -0·22], p=0·0012) and the imbalance in efficiently allocated spending (β=-1·38 [-1·97 to -0·78], p=0·0001) were both inversely associated with real GDP. All estimated coefficients were significantly different from zero at the 0·005 level. A striking imbalance exists between government spending on mental health and the related disease burden in the Americas, which disproportionately affects low-income countries and is likely to result in undertreatment, increased avoidable disability and mortality, decreased national economic output, and increased household-level health spending. Weatherhead Center for International Affairs, Harvard University.
Highlights
We considered three linear regression models, all in log–log form: (1) a regression of the proportion of total government health spending allocated to mental health services on real gross domestic product (GDP) per capita: Ln (% of government health spending allocated to mental health servicesc)=a1 + β1 Ln(GDPc) + ε1 (2) A regression of the proportion of mental health spending allocated to psychiatric hospitals on real GDP per capita: (3) A regression of imbalance in efficiently allocated spending on real GDP per capita: Ln((%MNSS disability-adjusted life-years (DALYs) 0·69 × schizophrenia DALYs) / (% mental health spending [% mental health spending × % psychiatric hospital spending]))c = a3 + β3 Ln(GDPc) + ε3
In 2015, non-communicable diseases (NCDs) accounted for 60% of total DALYs, of which 12% corresponded to MNSS, whereas in the Americas they accounted for 78% of total DALYs, of which 19% corresponded to MNSS
Median spending on mental health stands at around 2% of total government health spending, while mental disorders account for 12% of total DALYs and 35% of total years lived with disability (YLD) as per our estimates updated to 2015.2,5,6 Low-income countries spend around 0·5% of their health budget on mental health services, lowermiddle-income countries around 1·9%, upper-middleincome countries 2·4%, and high-income countries 5·1%
Summary
An epidemiological transition has largely shifted the global burden of disease from communicable, maternal, childhood, and nutritional disorders to non-communicable diseases (NCDs).[1,2] Mental health disorders represent a complex challenge given their high prevalence and disability burden, estimated as the highest among NCDs.[3,4,5,6] Yet, pervasive stigma, outdated practices, and organisational fragmentation still result in woefully inadequate responses by health systems to mental illness.[7,8] Further, traditional approaches to measuring the disease burden of mental health problems have led to underestimates because of methodological constraints, including arbitrary separation between psychiatric and neurological disorders, consideration of self-harm as a category outside mental illness, conflation of painful somatisation disorders with musculoskeletal disorders, exclusion of personality disorders, and inadequate consideration of the contribution of mental illness to excess deaths.[6]The aim of this study was to estimate the disease burden attributable to disorders affecting mental healthLancet Public Health 2019; 4: e89–96Published Online November 13, 2018 http://dx.doi.org/10.1016/ S2468-2667(18)30203-2This online publication has been corrected. An epidemiological transition has largely shifted the global burden of disease from communicable, maternal, childhood, and nutritional disorders to non-communicable diseases (NCDs).[1,2] Mental health disorders represent a complex challenge given their high prevalence and disability burden, estimated as the highest among NCDs.[3,4,5,6] Yet, pervasive stigma, outdated practices, and organisational fragmentation still result in woefully inadequate responses by health systems to mental illness.[7,8] Further, traditional approaches to measuring the disease burden of mental health problems have led to underestimates because of methodological constraints, including arbitrary separation between psychiatric and neurological disorders, consideration of self-harm as a category outside mental illness, conflation of painful somatisation disorders with musculoskeletal disorders, exclusion of personality disorders, and inadequate consideration of the contribution of mental illness to excess deaths.[6]. The aim of this study was to estimate the disease burden attributable to disorders affecting mental health. Published Online November 13, 2018 http://dx.doi.org/10.1016/ S2468-2667(18)30203-2. The corrected version first appeared at thelancet.com/public-health on February 6, 2019
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